Do you have questions about Kegel exercises after childbirth? You are not alone. Most women have heard they should be doing “Kegel” exercises to strengthen their pelvic floor muscles, especially after having a baby in order to reduce urinary leakage and pelvic organ prolapse risks. However, more often than not, the instructions given by the OB/GYN or childbirth educators are too vague or not specific enough to treat the real problem, and some people should not do Kegel exercises. If you have pelvic pain, exercising might be making the pain worse. Seeing a physical therapist who specializes in the pelvis may be the answer to your Kegel questions.

How do I know if I am doing them correctly? How many should I do? What position should I be in? Are you supposed to do them when you pee or when you are at a red light-which is it? Will it help with my urinary leakage? What about with my sex life?

These are common questions I hear in my practice as a pelvic floor physical therapist. I specialize in treating the muscular dysfunctions of the pelvic floor. A group of over 20 separate muscles that lie underneath the pelvic organs (the bladder and the bowels, the uterus and vagina in women, and the prostate in men), the pelvic floor acts to support the organs and gives us voluntary bowel and bladder control. Most people think their bowel, bladder, or genital troubles are due to problems in the organs themselves. Your bladder problem may really be a muscle problem.

The most frequent question I hear is, “What on earth can a physical therapist, of all people, do about my bladder or bowel problem or my pelvic pain?” A lot, actually.

The American Urological Association recently recommended pelvic floor physical therapy as an early treatment option for pelvic floor dysfunction, especially in those with pelvic pain. The pelvic floor muscles are skeletal muscles, which mean they are under your voluntary command. They are controlled by your thoughts, just like the muscles in your arms and legs, which means they can have the same type of problems as any other muscle. Weakness, poor endurance, poor coordination, and even painful tender points and scar tissue adhesions can occur in the pelvic floor muscles. Instead of causing difficulty with walking or lifting, pelvic floor muscle dysfunction can cause incontinence, pelvic organ prolapse, and even pain with intercourse.

So, what does a pelvic PT know?

Pelvic PT’s know that most bladder problems are really muscle problems. Like pinching a garden hose, the pelvic floor muscles contract around the urethra (your bladder tube) to give us bladder control. When you have the urge to urinate and “hold it”, your pelvic floor muscles are doing the holding.

If your pelvic floor muscles don’t have adequate strength, they can’t pinch the urethra tight enough to hold urine inside the bladder. If you have poor endurance in your pelvic floor, you might have trouble making it to the bathroom on time. If you have poor coordination, your pelvic floor muscles might not squeeze fast enough to counteract that cough or sneeze. The same can be said for bowel control, too.

Your average Kegel program is too simple to address these muscle complexities. Bladder and bowel control is dependent on the pelvic floor muscles working in harmony, not just being “strong”.

Think about it-does it make sense that just doing biceps curls would fix every arm problem? No, it doesn’t. Kegels can’t fix every pelvic problem, either. There are many types of pelvic exercises. Kegels are just one type of exercise a pelvic physical therapist might prescribe.

Pelvic PT’s understand pelvic pain.To put it simply, pain inhibits normal muscle function. When we hurt, we don’t move normally. It is easy to see if someone has pain in their knee or ankle – they limp! The pelvic floor is an inside muscle, which makes seeing its dysfunction more difficult.

If your pelvic floor muscles are painful due to an episiotomy scar or other birth trauma, repetitiously contracting the muscles may make your pain worse. You may need exercises that stretch rather than strengthen your pelvic floor. Only a trained pelvic floor physical therapist can evaluate your pelvic muscle function and then prescribe the right type of pelvic floor exercise program for you.

Pelvic PT’s know how to individualize an exercise program. A Physical Therapist uses movement to treat the body the same way a doctor uses medicine. Exercises are prescribed and are individualized to the patient. A triathlete or cross-fitter should, and will, have a different program compared to someone who has never really exercised. Your “movement medicine” is designed to fit your life and the demands your lifestyle puts on your body.

The pelvic floor is not an isolated muscle group. It is anatomically connected to your hips and is a part of your inner core of muscles. Knowing how connected the pelvic floor is to the spine and legs, it is no surprise that back pain and balance troubles are linked with incontinence. In a recent study, 52% of people with low back pain also reported having some form of pelvic floor dysfunction (voiding dysfunction, urinary incontinence, sexual dysfunction and/or constipation). Over 80% of those with pain said their pelvic floor symptoms began about the same time as their low back or pelvic pain did.

If you have pelvic pain, back pain, tailbone pain, or genital pain, it is very likely your pelvic floor is part of the problem. Seeing a pelvic floor physical therapist who can tailor a program for you can be a part of your solution.

Pelvic PT’s know a lot about Kegel exercises. A short history lessonThere was a Dr. Kegel. He was a Mayo-trained surgeon who became interested in finding non-surgical treatment options for incontinence in post-partum women in the 1930’s. He did not “invent” the exercises. Therapists in England had been teaching pelvic and pelvic floor exercises since the late 1800’s to new mothers in the maternity wards. He was, however, the first to apply the scientific method to prove pelvic exercises actually worked to reduce urinary incontinence. After decades of research on the best methods on how to teach the exercises, he published his results in 1948. His approach was 84% effective in curing incontinence symptoms. So what happened? The methods Dr. Kegel developed in the lab just didn’t translate well into modern medical practice Unfortunately, in today’s post-partum healthcare world, Dr. Kegel’s methods of teaching pelvic exercises have been replaced with a brochure that new moms are handed as they leave the OB/GYN’s office. Most well-meaning doctors didn’t have the time or resources to duplicate Dr. Kegel’s methods in their clinics. Over the years, the verbal or written description of how to “squeeze down there” started to replace the individualized approach Dr. Kegel was able to take in his research. Dr. Kegel advocated that without one-on-one instruction physical instruction by a trained practitioner, most women would not be able identify the right muscle, therefore making the exercises ineffective. Decades after this assertion was published, multiple studies now support Dr. Kegel’s early observations. One study found that in women who were given only verbal and written instructions on Kegel exercises in an OB/GYN’s office, less than half could demonstrate a correct pelvic floor contraction.How would Dr. Kegel teach you how to do Kegel exercises? First, he would look at and palpate your pelvic floor to make sure you were using the right muscle group. He would then use an internal vaginal pressure sensor called a perineometer, an early type of biofeedback, allowing you to “see” your internal pelvic floor muscles working. He would progress your exercises as you became stronger. You would be instructed several times over the course of weeks or even months.If you have tried Kegels on your own and not gotten the results you wanted, maybe you need a “Kegel coach” – a pelvic physical therapist who has the time (our appointment are an hour long), the equipment (we use modernized biofeedback methods), and the knowledge (it’s our specialty) to evaluate your Kegel skills and then develop an exercise plan especially for you.***Dr. Heather S. Rader, PT, DPT, PRPC, BCB-PMD is a pelvic physical therapist at Sher Pelvic Health and Healing. She holds certifications in pelvic rehabilitation and biofeedback for pelvic muscle dysfunction. She has been a pelvic specialist for over 15 years and is a pelvic floor rehab educator.

The important findings are: During the subsequent ipsilateral leg lift (lifting the leg on the same side as the painful pelvic region):* pre-activation in the pelvic floor muscles was observed in 36% of women with pelvic girdle pain and in 91% of pain-free women*Compared to pain-free women, women with pelvic girdle pain also showed significantly later onset time in both the pelvic floor muscles and the muscles of the lower lateral abdominal wall

We know from previous studies (one of many) that there are many prognostic factors that can relate to persistent pelvic girdle pain such as age, muscle function, disability, and previous fitness level/pain levels . What does this all mean for patients ? How can we help those of you who are dealing with lumbar and pelvic pain , even years after having a baby?

The key is to address each patient individually. There are numerous layers to the pain experience - beyond just the location of pain. It is likely also simplistic and erroneous to assume that the pelvis is "too unstable" or that the sacroiliac joint is just hypermobile (there are certainly cases of people who have hypermobility as a component such as with Ehler's Danlos Syndrome, but even then, there are other factors). If you find that you have been seeing other healthcare professionals for years telling you that your leg, sacroiliac joint, or pelvis keeps going "out," that's likely not the issue. From a whole-person perspective, there are factors to consider such as hormonal, physical, sleep/lifestyle, social, and psychological (not "it's-in-your-head type, but rather effects of anxiety, stress, previous pain, or previous trauma, etc) . Therefore, addressing these factors AND taking a closer look at the pre-activation/motor control of the muscles and general movement patterns is an ideal approach.

If you are a patient dealing with pelvic girdle pain, sacroiliac joint pain, lower back pain after having a baby (even years later), there's a lot of hope for getting better! A pelvic physical therapist can assess you individually to facilitate the best plan for your daily life and also provide an optimal exercise plan to guide you to relatively pain-free movements! This goes beyond simply giving a list of exercises and saying good luck! That's why so many women continue to have pain for years later. We can also work closely with your pregnancy /postpartum specialists - there are some incredible ones out there too.

For professionals - The key is how do we improve/facilitate the proposed disturbed motor activation patterns that influence women's ability to stabilize the pelvis during leg? How much do we train "pre-activation?"There seem to be distinct professional views: 1. Some say just get patients moving in pain-free ways and this will help with improving neural/motor activation and don't focus on pre-activation and minutia; or 2. Others focus heavily on individual "pre-activation," movement patterns, segmental/"core" strengthening. Couldn't it be the case that we include both of these strategies (and individualize as needed) - not so much thinking we are increasing strength, but rather improving motor patterns and activation on a neural level?

Another consideration: EMG testing can be subpar for understanding the underlying issue regarding muscle activation. In other words, patients may not be pre-activating pelvic floor as a result of shortening of the muscles rather than simply not activating due to weakness or other. Therefore, just working on activating the pelvic floor prior to an activity, may not be the best treatment. We still have to look at each individual and assess all of the variables.** Did you know that Tracy Sher, MPT, CSCS and Alma Bautista, SPT, at Sher Pelvic Health are both Certified MuTu Pros™ in postnatal fitness? Minal Saraf, MSPT also specializes in Pelvic PT for pregnancy/postnatal.

When Can I Return to Exercise After Having a Baby?

In addition to those general guidelines, it is important to remember that having a baby via C-section or vaginal delivery is a big deal! Your body is incredible, strong and beautiful. Honor your body during this time and allow the tissues to heal ( vaginal delivery as an extreme sport and returning to exercise after a C-section).
​Movement is very beneficial to healing such as walking, breathing exercises and pelvic floor exercises. Generally, after 4-8 weeks (based on your medical visits), you can increase to higher intensity aerobic exercise and weights. If you try to go back to the same exact exercises that you were doing during pregnancy or before, you may realize you have changes affecting the way you move and feel such as: scar tissue adhesions at your abdomen, a prolapse starting, separation of the abdominal muscles, leaking with jumping.

What if I Have Pelvic Organ Prolapse, Urinary Leakage or Diastasis Recti (abdominal separation causing a "pooch")?

Once you are cleared by your OB medically, we highly recommend you see a Pelvic Physical Therapist (Women's Health Physical Therapist). This is exactly what we do! We help you maximize your pelvic, abdominal, and back health to be able to return fully to your daily activities, including exercise programs. We can do postnatal screenings to identify these conditions and provide individualized treatment and home programs for you.

What are Good Online Postnatal Exercise Programs (either before or after Pelvic PT)

There are numerous postnatal exercise programs out there, which is why we want to highlight the very best! The programs listed here are ones that specifically take pelvic health into consideration. They are developed by fitness trainers or PTs we trust.
** These exercise programs are not just for up to 1 year postnatal. They are safe for most people at any age because they are meant to facilitate proper form and optimal pelvic/core health.
** Concern: Classes that focus on the BOOT CAMP mentality . Some of the exercises can be okay, but often women are pushed to do crunches, planks, high-intensity jogging and jumping with the motto "get your body back into shape quickly." These exercises are typically not appropriate for many women in the first year after baby. Many women go to countless exercise classes for their abdominals only to learn that it was making the diastasis recti and pelvic floor issues worse.
** We receive questions about the Tupler Technique often. It involves using a splint for a certain period of time while doing specific exercises. It can work for some, but we find that it is not applicable to daily function and many women have difficulty adhering to the program. We didn't feel comfortable putting it on our "best" list.
* We will continue to modify and add to this list.

We recommend this to new moms in conjunction with our pelvic PT sessions OR this program can serve as a stepping stone to more advanced exercise programs (getting back to high-intensity weight lifting classes and/or aerobic exercises) . Tracy Sher serves as Medical Advisor for MuTu and affiliate and fully endorses the program. The online program also includes access to a very active online support group. The founder, Wendy Powell, is very passionate about this system and heavily involved in online support.
* We will soon offer LIVE MuTu classes in Orlando starting in July/August of 2016!

"Wholesome fitness for the whole family. You crave modesty, affordability, and accountability."

Another program that is always rated with high satisfaction is Fit2B , by Beth Learn. The primary feature is a monthly or yearly membership that provides online options such as: access to over 100 workouts, a supportive Facebook community, discounts on eCourses , and a Fit2B mobile app.

"Hab-it: Pelvic Floor is a DVD [now digitial download] that gives women suffering from the symptoms of a weakened pelvic floor (urinary incontinence, pelvic prolapse) the experience of working with a physical therapist from the comforts of home. The intent of the DVD is to help, if not eliminate, the symptoms of a weakened pelvic floor...designed with input from physicians, physical therapists, and real patients to ensure that viewers receive expert guidance that addresses the most common mistakes and frustrations of physical therapy"

The website features a series of digital download exercise programs: Hab-It Pelvic Floor Exercises, 7 Day Advanced Stabilization Program, Interval Cardio Workout, Interval Plyometric Workout.
We heard a lot about this from patients. They enjoyed the program, but were looking for more individualized programs as well.

THE PELVIC FLOOR PISTON - FOUNDATION FOR FITNESS DIGITAL DOWNLOAD

"The pelvic floor has long been the only muscle targeted in the battle against incontinence, and yet ignored in our pursuit of a strong ‘core’. New research has helped us understand that the pelvic floor is actually a critical part of the ‘core’ team and collectively that team works together to keep your center anchored and dry. Integrated teamwork, linked to the up and down pistoning action of our breath, provides a sturdy foundation that supports our joints and movement, accelerates fitness, and keeps us dry. Also recommended for minimal to moderate prolapse, diastasis, and pelvic pain."

Physical Therapist Julie Wiebe is a leading clinician and educator on the topics of returning to high-level athletics after changes at the pelvic floor and core. Foundation for Fitness is your first step toward resolving leaks and restoring a strong foundation for your movement and fitness.
* This is an educational online course rather than an exercise system. Highly recommended to understand the pressure system of the core. You can view this as a great complement to the full programs listed above.

We hope this has been helpful! If you would like to set up a consultation with one of our Pelvic PTs , you can fill out the registration form on our welcome page HERE or call 407-900-2876

Did you know that the abdominal muscles play an integral role in pelvic health? This is an introductory post about the abdominal muscle anatomy. In future posts, we will highlight how this relates to conditions such as diastasis recti, abdominal pain, pelvic pain, hernias, hip dysfunction and much more.

Abdominal Anatomy Facts

The transversus abdominis is the deepest of the abdominal muscles (under the obliques and rectus abdominis) and is a very important "core muscle."

All of the abdominal muscles have an attachment point at (or into a tendinous expansion of) the linea alba - connective tissue raphe formed between the rectus abdominis where the decussating tendinous fibers of the lateral abdominal wall aponeuroses. The linea alba is the region where we see conditions such as diastasis recti.

It is very difficult to isolate abdominal muscles when exercising. Muscles function synergistically. When exercise specialists state "focus on the rectus abdominus," for example, there are movements that will improve that muscle's activation, but other muscles will fire as well. We often cue patients to activate transversus abdominus and minimize rectus or oblique firing. We cannot totally avoid synergistic muscle activation, but we can facilitate activating certain muscles more effectively.

The term "core" is often times synonymous with abdominal muscles. The true "core" is made up of the pelvic floor muscles, transversus abdominis, the diaphragm, and multifidi low back muscles.

Basics: Abdominal Wall Muscles Video Tutorial

Abdominal Muscles - Diagram

How To Get Your Post-Baby GROOVE Back - A Mini-Retreat for WomenFriday, October 17, 10 am - 2pm

We are hosting some TOP international women's health speakers right here in Central Florida! Don't miss out on this opportunityIf you are pregnant or have small children, THIS is the event you should attend. So much to hear and experience - all the things you wish your OB/GYN told you...all of the ways to get your body healthy and you feeling sexy again - from the best fitness and sex experts too!Join us at Inspirit Yoga Studio (near the Orlando Convention Center) on Friday, October 17, from 10 am - 2pm! To find out details and register go to: www.postbabygroove.eventbrite.com

If you have additional questions, email info@sherpelvic.com or call 407-900-2876* We encourage you to take this time for YOU. However, we understand that you may want or need to bring your small children. See our FAQs on the event page.